CVS Flashcards
AF
Mid-systolic murmur with systolic click at apex
Mitral valve prolapse AND regurg
Someone with chest pain radiating to the back and collapse. Presents with BP in the right arm much higher than in the left (210/100 vs 150/100) . Weakness in L arm and leg. Dx?
Aortic dissection
Man comes in with left side central chest pain, and pain on inspiration. ECG given.
Acute pericarditis (widespread ST elevation and PR depression)
Old guy with T2DM. Only medication he is on is Insulin. Comes in for routine diabetes check. Proteinuria in urine. BP consistently in 160s. ? what medication to start?
ACE-inhib (e.g. quinapril)
IVDU, signs of right sided heart failure, elevated JVP with v waves, pansystolic murmur at LLSE, what’s the cause?
Mitral regurg
Mitral stenosis
Aortic regurg
Aortic stenosis
Tricuspid regurg
Tricuspid stenosis
pansystolic murmur at LLSE = from location can deduce this is tricuspid.
Systolic - must be regurgitation
Also regurg following IVDU infective endocarditis much more common than stenosis
Some guy at urgent docs here on a business trip. He keeps having jaw pain. History of HTN. He had severe jaw pain when walking back from lunch today, but since resolved. Oral cavity and jaw appear fine on exam. What is an important immediate investigation you must do? Was the wording not something like what initial management would you do?
a. Cardiology referral
b. Dentist referral
c. ECG
d. Dental X-ray
e. Analgesia
ECG
Asian lady on microgynon and salbutamol. Came in with pleuritic CP and dyspnoea. High JVP. hypotensive. Xray given [looked normal] and an ECG underneath [RV strain pattern with ?sinus or RBBB]. What would be the most appropriate treatment?
· Heparin
· Pericardiocentesis
· Cardioversion
- IV morphine
Heparin
Sounds like a pulmonary embolism
Microgynon = combined OC
Fijian guy in a RTA, where he rear ended someone. Now has pain, ventricular ectopics, irregular HR and pulse of 100, JVP not elevated, BP 120/80. Can hear an anterior rub on auscultation. ECG shows multiple PVCs.
· Cardiac tamponade
· Aortic dissection
· Atrial fibrillation
· Myocardial infarction
· Myocardial contusion
· Pericarditis
Myocardial contusion (bruising)
Chick with chest pain associated with inspiration. Hemodynamically stable BP 100-120ish/80ish and HR around 80
?maybe has fever
ECG shows Global ST - concave up,
Treatment?
NSAIDs for pericarditis
Guy ~38 years old. Returned from recent overseas business trip. ECG + history. Sudden chest pain, short of breath, sweaty. Hypotensive. Appears to be ST elevation in aVF (and leads II, III, +1 with some ST depression in anteroseptal leads?
Inferior MI
28yo female has hypertension, has history of fevers and enuresis as a child, what is
the hypertension
Essential hypertension, PCKD, reflux nephropathy, analgesic nephropathy, chronic
glomerulonephritis
This sounds like recurrent UTIs in childhood leading to kidney damage?
Probably reflux caused the recurrent UTIs –> enuresis, fevers…
Eventually leads to high blood pressure.
AF in older person
Amiodarone and anticoagulant,
beta blocker,
CCB, amiodarone anticoag and cardioversion in 6 wks,
cardiovert
New onset AF <48 hours or haemodynamic instability could do cardioversion…
But i think this patient would be treated with beta-blocker and anticoagulation (warfarin/dabigatrin) - prob the best answer here is amiodarone + anticoag
ECG of VT (wide complex QRS tachycardia). Treatment?
If acute –> cardiovert
What happens in digoxin toxicity?
Hyperkalemia
Pt with HTN with history of gout and asthma, already on ACEI but HTN still
uncontrolled, next drug to use?
CCB
BNP
Produced in atria,
low levels in heart failure, high levels in CKD,
is an anti-natriuretic
Peptide
High levels in CKD
chest pain 1-3 days after MI. changes with position
Pericarditis
man accident. you don’t have a stethoscope. JVP is normal. percussion is normal. He
has cold peripheries. what is the cause of shock in this man?
?aortic dissection
25-year-old found dead in bed prev. Healthy
Hypertrophic cardiomyopathy
Obese patient with symptoms OSA, has (+) JVP bilaterally measured up to 6 cm.
jugular waves are present, lung function test given, raised JVP due to
RV failure due to chronic ischemia
First line treatment for essential hypertension
Thiazide diuretic?
‘First-line choices can be a thiazide, an ACE inhibitor or ARB, or a calcium channel blocker’
Best investigation for heart failure
bpac says ECG, blood tests for BNP too but not all that specific
Murmur after MI, loud, harsh pansystolic in lower left sternal border
VSD from infarction
(A loud, harsh, holosystolic murmur at the lower left sternal border is common)
Patient with chest pain on exertion, now pain while sitting/radiating to arms
Acute coronary syndrome e.g. unstable angina
Patient presents with markedly raised jvp, R>L measured up to 8cm, jugular wave
can’t be seen. Mediastinal enlargement. Most likely cause is
SVC obstruction
10 year old with bilateral calf pain on walking and weak femoral pulses
coarctation of the aorta
Can cause low blood flow to legs, radio-femoral delay
MI = 2 days later breathless + pan systolic murmur
MR due to papillary muscle rupture
Girl with chest pain, SOB, on OCP. Chest X-ray and ECG. What do you treat her
with?
Heparin (PE)
Patient with AF given warfarin, what other drug would you give
Beta blocker first line
Asian lady with dyspnoea but normal cxr and tachy ecg, management. Has
asthma and on pill comes in with acute dyspnoea and pleuritic pain. Hyperinflated
lungs. ECG shows S1,Q3,T3.
LMWH or thrombolysis (only thrombolyse in cases of massive/saddle PE)
Man with raised JVP, soft heart sounds. Investigation?
Echo as this sounds like tamponade. (soft heart sounds)
40 y/o woman with paroxysmal AF with fast heart rate. What questions indicate
diagnosis?
Palpitations when you get excited? Sudden death in the family?
I have no idea.
60 y/o severe retrosternal chest pain radiating to left arm. Palpable radial pulse in
left arm but no pulse in right arm. Diagnosis?
Aortic dissection
ECG showing concave ST segment.
Pericarditis
70 y/o SOB on exertion. Dilated apex by 3cm. Diastolic murmur left sternal
border 3/6.
Aortic regurg
Middle aged lady with progressive SOB, only when she is is cycling to work in the
morning. No other significant history, ?maybe family history of heart failure. All exams are fine. which investigation?
Exercise ECG.
CXR
Echo
Spirometry
Haemoglobin estimation - simple anaemia
Lol i feel like if chest pain would do an exercise ECG…
But just SOB - maybe just bloods at this point to see Hb + BNP…
Post MI few days about to be discharged with chest pain, worse when lying flat and on
inspiration, relieve by sitting forwards
Pericarditis
HR 40. Treatment?
Atropine for bradycardia.
Man with AAA which investigation do you use?
Duplex USS
Māori man with non-acute hx of angina and reduced exercise intolerance, shows ECG
with ST depressions in ALL leads presents with increasing fatigue, on thiazide. Flattened T
waves. ECG also showed some subtle U waves.
Diagnosis?
Hypokalemia
(thiazides!!)
Elderly man has just started taking doxazosin. Had recently had falls. Why?
Postural hypotension
Single ECG strip showing 1st degree heart block, what vessel is most likely to be diseased?
RCA supplies both SA + AV nodes. (atrioventricular node artery comes off RCA)
Asian lady on microgynon (COCP) and salbutamol. Came in with pleuritic chest pain and acute dyspnoea. High JVP. Normal X-ray, ECG sinus tachy with an RV strain pattern, S1Q3T3. What would be the most appropriate treatment?
a) Cardioversion
b) Defibrillate
c) IM Adrenaline
d) Low molecular weight heparin
e) Pericardiocentesis
f) Thoracocentesis
g) Atropine
Low molecular weight heparin
(this is a PE)
40 year old Maori nurse presents with a history of palpitations. ECG shows irregularly irregular rhythm, no p waves, f waves. What is it?
AF
Young women with chest pain associated with inspiration and fever. Hemodynamically stable BP 100-120/80 and HR 80. ECG given. Global saddle shaped ST elevation. Management?
a) Cardiac catheter
b) Thrombolytics
c) IV GTN
d) Oral NSAID
e) Exercise/stress-test ECG
This is acute paricarditis
??? AAA??
Tokeleuan male with 4.5cm AAA. What do you use to monitor?
a) Duplex USS
b) MRI
c) CT
Duplex USS
Monitor 3-6 months
Over 5.5 needs repair
Guy has epigastric pain for a few hours, which radiates to back. He dies before the ambos get to him. Diagnosis?
Ruptured AAA
Māori man with non-acute hx of angina and reduced exercise intolerance, shows ECG with ST depressions in ALL leads presents with increasing fatigue, on thiazide. Flattened T waves. ECG also showed some subtle U waves. Cause?
Hypokalemia
Man with acute pleuritic pain with SOB. No risk factors. First investigation?
a) D dimer
b) CXR
c) CTPA
d) VQ scan
e) Doppler USS
D-dimer i think
Long PR interval = AV node dysfunction
What supplies the AV node?
The AVN branch of RCA
Man with raised JVP, soft heart sounds. Investigation? a) Echo
b) ECG c) CXR
Known as Beck’s triad: low BP, distended jugular veins, muffled heart sounds
= cardiac tamponade. Investigation = ECHO
Man with hypertension not controlled by quinapril. Has asthma and gout. What treatment?
a) Add CCB
b) Add thiazide
c) Swap to CCB
d) Add beta blocker
No beta blocker (asthma), dont do thiazide (gout), add CCB
Patient with AF given warfarin. What other drug would you give?
a) Beta blocker
b) Diltiazem
c) Verapamil
d) Amiodarone
Needs something for rate/rhythm control…
Beta-blocker
75 year old man on cilazapril, metoprolol, furosemide and aspirin. Ejection fraction of 29%. Breathless. Cr 10, K+ 4. What is next treatment?
a) Spironolactone b) Diltiazem
c) Digoxin
Spirinolactone
HFrEF = reduced EF (<50%) – systolic dysfunction
- Start with diuretic (reduce Na/water retention) add ACEi/ARB at max dose (reduce
afterload) + beta blocker (reduce SNA)
- If still sx despite max dose ACEi add spironolactone if still sx add Entresto or digoxin
HFpEF = preserved EF (>=50%) – diastolic dysfunction
- Start with diuretic add ACEi or beta blocker (don’t need max dose)
- Add digoxin if AF
Patient had an MI. 2 days later breathless and new pan-systolic murmur at apex. Diagnosis?
apex = mitral, regurgitation due to papillary muscle rupture
Patient had an MI. Developed muffled heart sounds. Diagnosis?
a) Papillary muscle rupture
b) Ventricular free wall rupture
c) Pericarditis
Tamponade - i think ventricular free wall rupture
Patient had an MI. Developed pleuritic chest pain and pericardial rub. Diagnosis?
a) Papillary muscle rupture
b) Ventricular free wall rupture
c) Pericarditis/Dressler syndrome
Pericarditis/Dressler syndrome
dressler occurs a few weeks later - immune mediated response
Patient with CHF, SOB and bilateral pulmonary oedema. How do you transport them?
a) Transport sitting in ambulance
b) Transport lying down in ambulance
c) Car
d) Walk
e) Scooter
Transport sitting in ambulance
Patient comes to GP with BP 150/100 and asymptomatic. Treatment? a) Bendroflumethiazide
b) Furosemide
c) Cilazapril
d) Amlodipine
Essential HTN tx: thiazide = 1st line, CCB = 2nd line - ACEi/ARB = DM/HF, BB = post-MI
Best investigation for heart failure?
a) Rest ECG
b) Exercise ECG
c) BNP
d) Echo
ECHO = gold standard
25-year-old found dead in bed previously healthy. Family history of sudden death at young age. Most likely cause of death?
a) Restrictive cardiomyopathy
b) Hypertrophic cardiomyopathy
c) Dilated cardiomyopathy
d) Myocardial infarction
Hypertrophic cardiomyopathy - genetic hx, sudden death
Obese patient with symptoms OSA, has JVP bilaterally measured up to 6 cm. Jugular waves are present. Raised JVP due to
RV failure due to chronic ischaemia
Man in accident. You don’t have a stethoscope. JVP is normal. Percussion is normal. He has cold peripheries. What is the cause of shock in this man?
Aortic dissection
Man just returned from a pacemaker insertion. HR 100, RR high, muffled heart sounds, high JVP +++. ECG showed AF. What imaging do you do?
a) Echocardiogram b) CXR
c) CT
Pacemaker insertion wire through heart cardiac tamponade
muffled heart sounds = cardiac tamponade = ECHO
